ࡱ> qsp` fjbjb l|c|c; z z z z    H PPP8,H d*L````1Do)q)q)q)q)q)q),H,R.) u"uu)uz z ``U*uuuuz l` `o)u& : z z z z uo)uur&T , '@ Pu&'4*0d*&J/uJ/'u H H dH H Profile: Functional To assist workers/practitioners to screen for consumer s need for assistance with activities of dailyliving.Consumer Name:  FORMTEXT       Date of Birth: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Sex:  FORMTEXT       UR Number:  FORMTEXT       or affix label hereQuestions to ask the consumer (or the person who represents the consumer). AreaScreening QuestionsComments (include specific activities where assistance is needed; current formal or informal assistance provided; use of or need for aids and equipment; need for referral for functional assessment)DomesticDo you have any difficulty or need assistance at home with domestic activities? e.g. Doing your housework and laundry? Preparing meals for yourself? Shopping for food and household items? Other please specify FORMCHECKBOX  Yes  FORMCHECKBOX  No Details:  FORMTEXT      PersonalDo you have any difficulty or need assistance with: Dressing or grooming? Having a bath or shower? Other  please specify FORMCHECKBOX  Yes  FORMCHECKBOX  No Details:  FORMTEXT      MobilityDo you have difficulty or need assistance with mobility, for example walking or moving around the house? Prompt for use of aids, wheel chairs. FORMCHECKBOX  Yes  FORMCHECKBOX  No Details:  FORMTEXT      TransportDo you have difficulty or need assistance with transport for example using cars or public transport? FORMCHECKBOX  Yes  FORMCHECKBOX  No Details:  FORMTEXT      OtherDo you have difficulty or need assistance with other activities such as: Managing money? Organising and taking your medications? Other  please specify. FORMCHECKBOX  Yes  FORMCHECKBOX  No Details:  FORMTEXT      NOTE: THE FOLLOWING QUESTIONS ARE NOT INTENDED TO BE ASKED DIRECTLY OF THE CLIENTCognitionDoes the person have any memory problems or get confused? FORMCHECKBOX  Yes  FORMCHECKBOX  No Details (include source of information):  FORMTEXT      Challenging behavioursDoes the person have behavioural problems for example aggression, wandering or agitation? FORMCHECKBOX  Yes  FORMCHECKBOX  No Details (include source of information):  FORMTEXT       Referral Recommended To:  FORMTEXT       Produced by the Victorian Department of Human Services, 2006This information collected by:F Page 1 of 1Name:  FORMTEXT      Position/Agency:  FORMTEXT      Sign:Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Contact number:  FORMTEXT       Functional &(<>Ljl,DFZ\j, n p t u v   S T U c d e n o } jyh3vUh3vB*phh3v5CJOJQJ h3vCJj@h3vUjh3vUj`h3vUjh3vUjth3vU h3v5jh3vUjh3vUh3v4(N.l+$$Ifa$l +$Ifl *$Ifl $Ifl $Ifl $Ifl  DFd, 6 ^ VR@@$Ifl kd$$Ifl Fd'd&  t 0'    2 l2q4l4n4alp ^ u v  dTB0)$Ifl $Ifl $Ifl kd$$IflF7'n0'6    4 l4ald$Ifl   ; T   " Ukd$$Ifl5F7'n0'6    4 l4al$Ifl )$Ifl } ~    "    4 6 8 J L h j l 246PRfhj h3vUj) h3vUjh3vUjh3vUj h3vUjh3vUh3vB*ph h3vCJjh3vUmHnHujah3vUh3vjh3vUjh3vU2"  t Ckd$$IflF7'n0'6    4 l4al$Ifl )$Ifl $Ifl  >xzXWkd $$IflF7'n0'6    4 l4al $Ifl $Ifl  hjtvxzXZvxz02NPRdfl,jh3vU h3v5j h3vUje h3vUj h3vUh3vB*phj h3vUjG h3vUj h3vU h3vCJh3vjh3vUmHnHujh3vU40wgUCCCg)$Ifl $Ifl $Ifl kd/ $$IflF7'n0'6    4 l4alngU$Ifl kdM$$IflF7'n0'6    4 l4al$Ifl npV$Ifl _kd$$Ifl''0'64 l4al,.JLN dfz|~ln}}w h3v0Jh3v5CJOJQJmH sH h3v5CJOJQJmH sH jh3vUjh3vUj3h3vUjh3vUh3vB*phjh3vUmHnHujh3vUjh3vUh3vjh3vU+wgggg$Ifl kd$$IflF7'n0'6    4 l4alwue$Ifl kd$$IflF7'n0'6    4 l4allsc$$Ifl $ r  U"$Ifa$l  9r $Ifl ]kdS$$Ifl7''0'64lalln{k[%$Ifl #$Ifl kd$$IflF ' 0'6    4 lal "68FHJTV|~.0>@Bf۽h3vCJOJQJmH sH jh3vUjh3vUjh3vUjh3vUh3vOJQJj!h3vUjh3vUjh3vUh3vh3v5CJOJQJmH sH h3v5OJQJ)Ho__"$Ifl kd$$Ifl0'  0'624 lalpHJV@k[[["$Ifl kd$$Ifl0 '  0'622U4 lalp@BDFHJ`bdMKIIIGII& kdk$$IflF '    0'6    22U4 lalpdf ({. 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